Citation Nr: 1301769 Decision Date: 01/16/13 Archive Date: 01/23/13 DOCKET NO. 10-44 066A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUE Entitlement to a rating in excess of 30 percent for posttraumatic stress disorder (PTSD). ATTORNEY FOR THE BOARD R. Anderson, Associate Counsel INTRODUCTION The appellant is a Veteran who served on active duty from October 1990 to January 2000. This matter is before the Board of Veterans' Appeals (Board) on appeal from an April 2010 rating decision of the Winston-Salem, North Carolina, Department of Veterans Affairs (VA) Regional Office (RO) that granted service connection for post traumatic stress disorder (PTSD), rated 30 percent, effective May 9, 2008. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the Veteran if further action on his part is required. REMAND The Veterans Claim Assistance Act of 2000 (VCAA), 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012), and the regulations implementing it apply in the instant case. While the notice provisions of the VCAA appear to be satisfied, the Board is of the opinion that further development of the record is required to comply with VA's duty to assist the Veteran in the development of the facts pertinent to his claim. See 38 C.F.R. § 3.159 (2012). The Veteran argues that the Global Assessment of Functioning (GAF) scores assigned on VA examinations indicate that his PTSD is more severe than reflected by the 30 percent rating assigned. A review of the record found that the Veteran's symptoms of PTSD noted (in September 2007 to March 2010 VA treatment records as well as April 2010 VA examination) consistently reflect no more than mild impairment. However, the providers/examiners on those occasions have regularly assigned GAF scores in the mid to upper 50's (reflecting a moderate level of disability). See American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). The recurring apparent inconsistencies between the clinical reports of symptoms and the GAF scores have not been reconciled by any of the providers/examiners. It is well established in caselaw that GAF scores assigned are pertinent evidence that must be considered. Accordingly, another VA psychiatric examination to resolve the apparent inconsistencies in the record is necessary. Furthermore, the most recent medical evidence in the record regarding the severity of the Veteran's PTSD is the report of the April 2010 VA examination, and the most recent treatment record is dated in March 2010. The Veteran has reported he receives treatment at the Durham VA Medical Center (VAMC) and Raleigh Community-Based Outpatient Clinic (CBOC). The record shows that he was taking prescription medication for PTSD (with mixed results) and that there were discussions as to whether the prescription should be modified. Consequently, the record suggests that there likely are nearly 3 years of treatment records outstanding that are pertinent to the matter (may shed light on the severity of the PTSD during the evaluation period). Such records must be secured. Significantly, VA treatment records are constructively of record. The Veteran's cooperation will be needed to secure records of any private treatment he has received for PTSD during the evaluation period. Accordingly, the case is REMANDED for the following action: 1. The RO should ask the Veteran to identify the provider(s) of all evaluations and/or treatment he has received for PTSD since May 2008 (records of which are not already associated with the record) and to provide releases necessary for VA to obtain records of any such private evaluation or treatment. The RO should obtain for the record copies of the complete clinical records of the Veteran's evaluations and treatment for PTSD from all sources identified, to specifically include treatment records from the Durham VAMC (and Raleigh CBOC) from March 2010 to the present. 2. The RO should then arrange for the Veteran to be examined by a psychologist or psychiatrist to determine the severity of his PTSD. The Veteran's claims file must be reviewed by the examiner in conjunction with the examination. Based on examination and interview of the Veteran, and review of the record, the examiner should provide opinions that respond to the following: (a) Please identify all symptoms and impairment associated with the Veteran's PTSD, noting their frequency and severity. Please assign a GAF score and explain how it correlates with the symptoms found. (b) Please comment on the symptoms noted and GAF scores assigned in the course of the Veteran's 2007-2010 VA treatment and on April 2010 VA examination, reconciling any inconsistencies (i.e., between GAF scores assigned and symptoms noted). If any apparent inconsistencies cannot be reconciled, please explain why. The examiner should explain the rationale for all opinions in detail, citing to supporting factual data, as indicated. 3. The RO should then review the record, and readjudicate the claim for an increased rating. If the benefit sought remains denied, the RO should issue an appropriate supplemental statement of the case and afford the Veteran the opportunity to respond. The case should then be returned to the Board, if in order, for further review. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2002 & Supp. 2012). _________________________________________________ George R. Senyk Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2012).